Anesthesia Pharmacology: Anxiolytics and Sedative-Hypnotics
If non-pharmacological treatment of insomnia (such as moderate exercise) is not effective, drugs may have to be used.
Untreated chronic insomnia may have many adverse effects including a four-fold increase in serious accidents.
In addition to use of pharmacological agents, management of insomnia should include:
(a) a search for an underlying cause
(b) elimination of "performance anxiety" related to falling asleep
(c) adjusting the patient's biological clock such that sleepiness corresponds to the time of attempted sleep, and
(d) suppression of the use of alcohol or over-the-counter sleep aids
Ethanol should not be used to manage insomnia because of numerous adverse effects.
For insomnia, despite reducing sleep latency, it may cause sleep fragmentation.
Barbiturates and non-barbiturates for hypnosis
Barbiturates and non-barbiturates such as meprobamate have been used in the past for pharmacological hypnosis.
However, these drugs should be avoided:
Liabilities associated with barbiturate use include abuse potential, physical potentially life-threatening withdrawal reactions, dependence, and life-threatening toxicity with overdosage.
Hypnotics that act at benzodiazepine receptors and newer agents such as zolpidem (Ambien) are preferable to barbiturates because of:
Greater therapeutic index
Less disruption of sleep patterns and
Less danger of overdosage toxicity
If the patient does not experience daytime anxiety, those benzodiazepines that exhibit short half-lives are preferable.
These short half-life agents with no active metabolites or only short-acting metabolites are preferable because they do not induce daytime sedation.
Triazolam (Halcion) is an example of a short-acting agent that has been used as a hypnotic.
Short acting benzodiazepines may, however cause amnesia, early morning awakening, rebound daytime anxiety
Some patients who have insomnia also have daytime anxiety.
To manage those patients a longer-acting benzodiazepine may be appropriate.
Use of these agents may result in next-day cognitive impairment or delayed cognitive impairment as metabolites accumulate
Also, long-term benzodiazepine use may be a risk factor for long-term cognitive impairment.
Hobbs, W.R, Rall, T.W., and Verdoorn, T.A., Hypnotics and Sedatives: Ethanol In, Goodman and Gillman's The Pharmacologial Basis of Therapeutics,(Hardman, J.G, Limbird, L.E, Molinoff, P.B., Ruddon, R.W, and Gilman, A.G.,eds) TheMcGraw-Hill Companies, Inc.,1996, pp. 385-386.